Department of Radiation Oncology, University of Kansas Medical Center, Kansas City Kansas.
Department of Radiation Oncology, University Hospitals, Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland Ohio.
Int J Radiat Oncol Biol Phys. 2023 Jan 1;115(1):34-38. doi: 10.1016/j.ijrobp.2022.07.1839. Epub 2022 Jul 30.
Variation in commercial insurance coverage may lead to disparity in access to quality cancer care. We evaluated commercial insurance coverage determinations to assess the degree of variation across a national sample.
We identified the predominant carrier of commercial insurance in each state based on the 2020 US Government Accounting Office (GAO-21-34) report on insurance. For each state, publicly available medical policies from January 1, 2021 to January 31, 2021 were analyzed for coverage of 3 widely accepted procedures: hydrogel spacer, fluciclovine- positron emission tomography (PET), and intensity modulated radiation in low volume metastatic prostate cancer.
We analyzed 83 commercial medical policies across 51 states and District of Columbia. There was widespread variation in coverage policy. Hydrogel spacer was determined medically necessary in 9 states, mixed coverage in 8, not medically necessary in 22, and no available public policy in 12. Use of fluciclovine-PET required a minimum prostate specific antigen level of 2 ng/mL in 9 states, 1 ng/mL in 17, any minimum prostate specific antigen in 7, mixed coverage in 12, and no publicly available policy in 6. Intensity modulated radiation in low volume metastatic prostate cancer was medically necessary in 17 states, not necessary in 7, and not stated in 27. Insurance carriers often used external utilization management companies such as AIM-Healthcare and Evicore Healthcare. These determinations were more restrictive than carriers which did not use utilization management.
Commercial medical policies vary widely in medical necessity determinations for novel prostate cancer treatment procedures that are Food and Drug-approved and covered by Medicare. These data suggest a need for more consistent methodology for medical necessity determination to mitigate the current state where patients have unequal access to cancer procedures due to the location of residence and age.
商业保险覆盖范围的差异可能导致获得高质量癌症护理的机会不平等。我们评估了商业保险的承保决定，以评估全国样本的差异程度。
我们根据 2020 年美国政府问责局（GAO-21-34）关于保险的报告，确定了每个州的主要商业保险承保人。对于每个州，我们分析了 2021 年 1 月 1 日至 2021 年 1 月 31 日的公开医疗政策，以确定 3 种广泛接受的程序的覆盖范围：水凝胶间隔器、氟脱氧葡萄糖正电子发射断层扫描（FDG-PET）和低体积转移性前列腺癌的强度调制放射治疗。
我们分析了 51 个州和哥伦比亚特区的 83 项商业医疗政策。覆盖政策存在广泛差异。水凝胶间隔器在 9 个州被确定为医学必需，在 8 个州为混合覆盖，在 22 个州为非医学必需，在 12 个州无公开政策。在 9 个州，使用氟脱氧葡萄糖-PET 需要最低前列腺特异性抗原水平为 2ng/ml，在 17 个州为 1ng/ml，在 7 个州为任何最低前列腺特异性抗原，在 12 个州为混合覆盖，在 6 个州无公开政策。在低体积转移性前列腺癌中使用强度调制放射治疗在 17 个州为医学必需，在 7 个州为非必需，在 27 个州为未说明。保险公司经常使用外部利用管理公司，如 AIM-Healthcare 和 Evicore Healthcare。这些决定比不使用利用管理的保险公司更为严格。
商业医疗政策在新型前列腺癌治疗程序的医学必要性确定方面差异很大，这些程序已获得食品和药物管理局批准，并由医疗保险覆盖。这些数据表明，需要更一致的医学必要性确定方法，以减轻目前由于居住地和年龄的不同，患者获得癌症治疗程序机会不平等的状况。
